Wilkes Community College

Intramural Participation Form

Participant’s Name: _______________________________ Phone Number: (_____)_____________

Participant’s Address: ______________________________________________________________

Student I.D. Number: ______________________WCC Office365 username: ___________________

As a student or employee of Wilkes Community College, I understand that participation in the intramural program is on a voluntary basis. Participation within the intramural program may include ping pong, flag football, basketball, softball, volleyball, tennis, and other contact sports involving other students/employees of the college. _________ (initials)

I am aware that participation in sports can be a dangerous activity resulting in injury. I understand that the dangers and risks of participation in the intramural program here at Wilkes Community College include, but are not limited to, death, serious neck and spinal injuries, which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, tendons, muscles, and other aspects of the human body, and could influence my general health and wellbeing. _________(initials)

As a student or employee of Wilkes Community College, I understand that I alone am responsible for my actions during intramural participation. Prior to beginning any sport, I will have read the rules of that sport and will have no objections to the policies and procedures of the contest. I will work with the student activities coordinator and the intramural officials in providing a hazard-free environment in which to play, including informing officials of any dangerous conditions that may exist. I will also inform the officials of any medical conditions which may affect my participation or conditions that may arise due to competition or injury. ______ (initials)

I do certify that I am physically fit and am able to participate in the intramural program. I understand that the intramural program and Wilkes Community College are not responsible for any injury sustained during intramural competition. In the event I am injured during participation and cannot assist myself, the intramural officials at the scene have my permission to make arrangement for transportation to the nearest medical unit. I realize that I am responsible for all financial obligations occurring from my injury. _______ (initials)

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Intramural Participation Form 1

Emergency Contact / Medical Information

Emergency Contact Name_______________________ Relationship to Student: ________________

Phone Number:____________________________________________________________________

Known Allergies (Medication, Food, Etc.):_______________________________________________

Other Medical Conditions:____________________________________________________________

Current Prescription Medication:_______________________________________________________

Insurance Carrier: _______________________________Policy Number:______________________

I certify that I have read the previous “Intramural Participation Form” and finding no objections, do willingly sign this agreement. In addition, I do certify that I am covered by accident/medical insurance (as listed below) and that it will be in effect throughout the current academic year.

Student Name (Print)_______________________________________________________________ Student Signature:_________________________________________ Date: __________________

For students under the age of 18:

Parent/Guardian Name (Print) :________________________________________________________

Parent/Guardian Signature: _________________________________ Date: ____________________

Intramural Participation Form 2